Affidavit of No Discharge

OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
AFFIDAVIT OF NO DISCHARGE
This form applies to the following types of facilities: _________________________
1. Wastewater treatment facilities (CF Number)
a. Total retention by evaporation OK00____________________
b. Total retention by an approved Land Application Program (NPDES No. if Applicable)
2. Water Plants that treat backwash water by re-cycling or evaporation lagoons.
3. Swimming Pools that treat wastewater by evaporation in total retention lagoons.
4. Dairy farm wastewater treatment facilities.
5. Abandoned wastewater facilities.
1. FACILITY NAME: _________________________________________________________________________________________________________________
2. FACILITY ADDRESS:______________________________________________________________________________________________________________
3. FACILITY COUNTY:__________________________________LEGAL ( ¼ ¼ ¼ Sec., T, R)______________________________________________________
4. OWNER NAME AND ADDRESS:_____________________________________________________________________________________________________
5. CONTACT PERSON:__________________________________PHONE:____________________________TITLE:____________________________________
6. MAILING ADDRESS: ______________________________________________________________________________________________________________
7. TYPE OF FACILITY: WASTEWATER PLANT ( ) WATER PLANT ( ) SWIM. POOL ( ) DAIRY FARM ( ) OTHER ( )
8. TYPE OF TREATMENT: EVAPORATION ( ) LAND APPLICATION ( ) OTHER ( )
9. THIS FACILITY IS: PUBLICLY OWNED ( ) PRIVATELY OWNED ( )
10. THIS FACILITY WAS DESIGNED AS A:
( ) TOTAL RETENTION FACILITY WITH NO OUTFALL STRUCTURE SUCH AS AN OUTFALL BOX OR SLUICE GATE
( ) DISCHARGING FACILITY
11. HAS THIS FACILITY EVER HAD AN OPDES PERMIT TO DISCHARGE OR HAS THERE BEEN APPLICATION MADE FOR A PERMIT?
YES ( ) NPDES NO OK00____________ NO ( )
12. HAS THIS FACILITY EVER HAD AN OUTFALL BOX OR SLUICE GATE THAT COULD RESULT IN A WASTEWATER DISCHARGE? YES ( ) NO ( )
IF YES TO 12., GIVE A BRIEF EXPLANATION OF ANY CONSTRUCTION OR REUSE OF THE WASTEWATER THAT HAS RESULTED IN A CHANGE OF DISCHARGE STATUS __________________________________________________________________________________________________
13. DOES THE SWIMMING POOL, MOBILE HOME PARK, DAIRY FARM, ETC. CONTINUE TO GENERATE WASTEWATER ? YES ( ) NO ( )
IF YES TO 13., ARE THERE HOLDING PONDS AND/OR A LIFT STATION AT THE SITE? YES ( ) NO ( )
WHERE IS THE WASTEWATER TREATED? ____________________________________________________________________________________________
( ) TOTAL RETENTION FACILITY
( ) DISCHARGING FACILITY – NPDES NUMBER OK00________________________________
IF NO TO 13., HAS THE FACILITY OR ENTITY GENERATING THE WASTEWATER BEEN ABANDONED ? YES ( ) NO ( )
I, (Name) ________________________________________________, (Title) ____________________________________CERTIFY THAT THE ABOVE
INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT THE (Facility) ____________________________________________________ DOES NOT DISCHARGE WASTEWATER TO ANY WATERS OF THE STATE NOR DOES IT DISCHARGE TO ANY DITCH OR LAND AREA THAT COULD RESULT IN A DISCHARGE TO WATERS OF THE STATE. I CERTIFY THAT IN THE EVENT OF A HYDRAULIC LOAD INCREASE OR OTHER FACTORS OCCUR THAT WILL CAUS E THE FACILITY TO DISCHARGE WASTEWATER, AN APPLICATION FOR A PERMIT TO DISCHARGE WILL BE EXECUTED AT LEAST 180 DAYS PRIOR TO AN EXPECTED DISCHARGE. I UNDERSTAND THAT ALL UNEXPECTED UNPERMITTED DISCHARGES MUST BE REPORTED TO THE APPROPRIATE AGENCIES IMMEDIATELY.
I REQUEST THAT THE NPDES PERMIT/APPLICATION NUMBER OK00____________________________ BE DISCONTINUED.
APPLICANT REPRESENTATIVE : _______________________________________________________TITLE :___________________________________________
Subscribed and sworn to before me this _____ day of _________________________________, 19 _____.
NOTARY PUBLIC : ___________________________________________________________My commission expires: ______________________________________
Confirmed by Environmental Specialist: ____________________________________________R.S. NO. ___________________DATE:_________________________
Oklahoma Department of Environmental Quality – 707 N. Robinson St., P. O. Box 1677, Oklahoma City, OK 73101-1677
DEQ Form No. 530 E (9-98)
DEPARTMENT OF ENVIRONMENTAL QUALITY
AFFIDAVIT OF NO DISCHARGE – DEQ FORM 530 E (9-98)
INSTRUCTIONAL GUIDE
Please complete the Affidavit by responding to each item. DEQ cannot evaluate the Affidavit until the information requested is provided. If a specific question is not applicable to your facility please indicate by answering “NA” next to the question. Discharge permits and applications will not be discontinued until the Affidavit of No Discharge is considered complete. Any questions concerning the Affidavit may be directed to the Department of Environmental Quality or your local Deq representative. DO NOT ATTEMPT TO COMPLETE THE AFFIDAVIT BEFORE READING THESE INSTRUCTIONS.
1. Give the facility name in such a way as to distinguish it from other facilities owned by the same entity. Example : Denton Wastewater Treatment Facility – West.
2. Give the address of the actual facility including the city and zip code.
3. Give the county in which the facility is located as well as the legal description in ¼, ¼, ¼ Section, Township, Range or Longitude – Latitude.
4. Give the name and complete mailing address of the legal entity that owns the facility – city, town, public entity, company name, corporation or an individual.
5. Give the name, title and phone number of the person to contact for information concerning the facility.
6. Give the address where mail, concerning the facility is received.
7. Place an X next to the type of facility requesting a permit.
8. Place an X next to the type of treatment used by the facility.
9. Indicate whether the facility is owned by a public entity or a private individual(s).
10. Indicate whether the facility was originally designed to discharge (with an outfall) or as a total retention facility without an outfall structure.
11. If the facility is permitted at the present time or has applied for a permit, please indicate here and give the NPDES Number assigned by the DEQ and/or EPA.
12. Indicate whether the facility has ever had an outfall structure. If it has, then explain any modifications made in order to change the facility status to total retention.
13. If the facility has been abandoned, indicate here. Indicate whether the abandoned site has a holding pond or lift station for wastewater transferred to another site for treatment. Give the type of treatment used at the receiving facility and the DEQ and/or EPA assigned NPDES number for that facility if appropriate.
The owner/applicant or authorized representative must certify that all information is correct to the best of his/her knowledge and request any permit or application for permit on file (if any) be inactivated. The affidavit must be notarized and verified by your local DEQ representative before being submitted to the DEQ. Please note that the DEQ may require additional information.
Department of Environmental Quality – 707 N. Robinson, P. O. Box 1677, Oklahoma City, OK 73101-1677

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OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
AFFIDAVIT OF NO DISCHARGE
This form applies to the following types of facilities: _________________________
1. Wastewater treatment facilities (CF Number)
a. Total retention by evaporation OK00____________________
b. Total retention by an approved Land Application Program (NPDES No. if Applicable)
2. Water Plants that treat backwash water by re-cycling or evaporation lagoons.
3. Swimming Pools that treat wastewater by evaporation in total retention lagoons.
4. Dairy farm wastewater treatment facilities.
5. Abandoned wastewater facilities.
1. FACILITY NAME: _________________________________________________________________________________________________________________
2. FACILITY ADDRESS:______________________________________________________________________________________________________________
3. FACILITY COUNTY:__________________________________LEGAL ( ¼ ¼ ¼ Sec., T, R)______________________________________________________
4. OWNER NAME AND ADDRESS:_____________________________________________________________________________________________________
5. CONTACT PERSON:__________________________________PHONE:____________________________TITLE:____________________________________
6. MAILING ADDRESS: ______________________________________________________________________________________________________________
7. TYPE OF FACILITY: WASTEWATER PLANT ( ) WATER PLANT ( ) SWIM. POOL ( ) DAIRY FARM ( ) OTHER ( )
8. TYPE OF TREATMENT: EVAPORATION ( ) LAND APPLICATION ( ) OTHER ( )
9. THIS FACILITY IS: PUBLICLY OWNED ( ) PRIVATELY OWNED ( )
10. THIS FACILITY WAS DESIGNED AS A:
( ) TOTAL RETENTION FACILITY WITH NO OUTFALL STRUCTURE SUCH AS AN OUTFALL BOX OR SLUICE GATE
( ) DISCHARGING FACILITY
11. HAS THIS FACILITY EVER HAD AN OPDES PERMIT TO DISCHARGE OR HAS THERE BEEN APPLICATION MADE FOR A PERMIT?
YES ( ) NPDES NO OK00____________ NO ( )
12. HAS THIS FACILITY EVER HAD AN OUTFALL BOX OR SLUICE GATE THAT COULD RESULT IN A WASTEWATER DISCHARGE? YES ( ) NO ( )
IF YES TO 12., GIVE A BRIEF EXPLANATION OF ANY CONSTRUCTION OR REUSE OF THE WASTEWATER THAT HAS RESULTED IN A CHANGE OF DISCHARGE STATUS __________________________________________________________________________________________________
13. DOES THE SWIMMING POOL, MOBILE HOME PARK, DAIRY FARM, ETC. CONTINUE TO GENERATE WASTEWATER ? YES ( ) NO ( )
IF YES TO 13., ARE THERE HOLDING PONDS AND/OR A LIFT STATION AT THE SITE? YES ( ) NO ( )
WHERE IS THE WASTEWATER TREATED? ____________________________________________________________________________________________
( ) TOTAL RETENTION FACILITY
( ) DISCHARGING FACILITY – NPDES NUMBER OK00________________________________
IF NO TO 13., HAS THE FACILITY OR ENTITY GENERATING THE WASTEWATER BEEN ABANDONED ? YES ( ) NO ( )
I, (Name) ________________________________________________, (Title) ____________________________________CERTIFY THAT THE ABOVE
INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT THE (Facility) ____________________________________________________ DOES NOT DISCHARGE WASTEWATER TO ANY WATERS OF THE STATE NOR DOES IT DISCHARGE TO ANY DITCH OR LAND AREA THAT COULD RESULT IN A DISCHARGE TO WATERS OF THE STATE. I CERTIFY THAT IN THE EVENT OF A HYDRAULIC LOAD INCREASE OR OTHER FACTORS OCCUR THAT WILL CAUS E THE FACILITY TO DISCHARGE WASTEWATER, AN APPLICATION FOR A PERMIT TO DISCHARGE WILL BE EXECUTED AT LEAST 180 DAYS PRIOR TO AN EXPECTED DISCHARGE. I UNDERSTAND THAT ALL UNEXPECTED UNPERMITTED DISCHARGES MUST BE REPORTED TO THE APPROPRIATE AGENCIES IMMEDIATELY.
I REQUEST THAT THE NPDES PERMIT/APPLICATION NUMBER OK00____________________________ BE DISCONTINUED.
APPLICANT REPRESENTATIVE : _______________________________________________________TITLE :___________________________________________
Subscribed and sworn to before me this _____ day of _________________________________, 19 _____.
NOTARY PUBLIC : ___________________________________________________________My commission expires: ______________________________________
Confirmed by Environmental Specialist: ____________________________________________R.S. NO. ___________________DATE:_________________________
Oklahoma Department of Environmental Quality – 707 N. Robinson St., P. O. Box 1677, Oklahoma City, OK 73101-1677
DEQ Form No. 530 E (9-98)
DEPARTMENT OF ENVIRONMENTAL QUALITY
AFFIDAVIT OF NO DISCHARGE – DEQ FORM 530 E (9-98)
INSTRUCTIONAL GUIDE
Please complete the Affidavit by responding to each item. DEQ cannot evaluate the Affidavit until the information requested is provided. If a specific question is not applicable to your facility please indicate by answering “NA” next to the question. Discharge permits and applications will not be discontinued until the Affidavit of No Discharge is considered complete. Any questions concerning the Affidavit may be directed to the Department of Environmental Quality or your local Deq representative. DO NOT ATTEMPT TO COMPLETE THE AFFIDAVIT BEFORE READING THESE INSTRUCTIONS.
1. Give the facility name in such a way as to distinguish it from other facilities owned by the same entity. Example : Denton Wastewater Treatment Facility – West.
2. Give the address of the actual facility including the city and zip code.
3. Give the county in which the facility is located as well as the legal description in ¼, ¼, ¼ Section, Township, Range or Longitude – Latitude.
4. Give the name and complete mailing address of the legal entity that owns the facility – city, town, public entity, company name, corporation or an individual.
5. Give the name, title and phone number of the person to contact for information concerning the facility.
6. Give the address where mail, concerning the facility is received.
7. Place an X next to the type of facility requesting a permit.
8. Place an X next to the type of treatment used by the facility.
9. Indicate whether the facility is owned by a public entity or a private individual(s).
10. Indicate whether the facility was originally designed to discharge (with an outfall) or as a total retention facility without an outfall structure.
11. If the facility is permitted at the present time or has applied for a permit, please indicate here and give the NPDES Number assigned by the DEQ and/or EPA.
12. Indicate whether the facility has ever had an outfall structure. If it has, then explain any modifications made in order to change the facility status to total retention.
13. If the facility has been abandoned, indicate here. Indicate whether the abandoned site has a holding pond or lift station for wastewater transferred to another site for treatment. Give the type of treatment used at the receiving facility and the DEQ and/or EPA assigned NPDES number for that facility if appropriate.
The owner/applicant or authorized representative must certify that all information is correct to the best of his/her knowledge and request any permit or application for permit on file (if any) be inactivated. The affidavit must be notarized and verified by your local DEQ representative before being submitted to the DEQ. Please note that the DEQ may require additional information.
Department of Environmental Quality – 707 N. Robinson, P. O. Box 1677, Oklahoma City, OK 73101-1677